This K24 renewal application provides for salary support for Dr. Curtis to provide him the opportunity to spend 40% of his time mentoring pulmonary and critical care fellows, junior faculty, and other trainees in patient-oriented studies concerning chronic lung disease and patients with acute respiratory failure. This K24 award is supported by the Clinical Research Training Track of the fellowship training program of the Division of Pulmonary and Critical Care Medicine at the University of Washington. Dr-. Curtis is Director of this Training Track. The two projects are designed to improve the quality of end-of-life care for patients with acute respiratory failure (Project 1) and chronic lung disease (Project 2). The specific aims are: Project 1 1. Evaluate the effectiveness of a multi-faceted interdisciplinary intervention to improve the quality of care for patients dying in, or shortly after a stay in, the ICU with a randomized trial of 12 hospitals. The intervention will be evaluated with patient-level outcomes, controlling for clustering of patients within hospitals, including: a) the quality of dying and death (surveys by family and nurses);b) satisfaction with care (surveys by family and nurses);and c) the quality of end-of-life care (surveys by nurses and medical record review). 2. Examine the variability in, and predictors of, the quality of dying and end-of-life care in community ICUs with the purpose of identifying the current quality of end-of-life care in non-University settings and the institutional, clinician, and patient factors associated with the quality of this care. 3. Evaluate the successful and unsuccessful components of the intervention and describe the institutional and clinician facilitators and barriers to the intervention's implementation, with a focus on informing interventions to improve care for the dying at other sites. Project 2 1. Evaluate the efficacy of an interdisciplinary intervention to enhance patients'and families'ratings of communication about hope and prognosis for patients with severe COPD or metastatic cancer. 2. Evaluate the efficacy of this interdisciplinary intervention on patient and family depression and anxiety, hopefulness, patient-clinician concordance on patient treatment preferences, and evaluations of end-of-life care for patients with severe COPD or metastatic cancer. 3. Evaluate the stability of changes in the above outcomes over a 3 month period. 4. Evaluate the efficacy of the intervention for improving physician-nurse collaboration.